Refer your patient for a Home Medicines Review (HMR) if you suspect, or they tell you they are having difficulty managing their medicines

Explain options available to your patient, including continuing, changing or ceasing medicines, and discuss expected benefits and risks of harm, and potential outcomes

Ask your patient what their concerns and preferences are regarding medicines and make decisions together

Follow the steps outlined to align your patient’s medicine regimen with their individual circumstances and preferences

Pausing to review the medicine regimen

Complex multi-medicine regimens are increasingly common, especially in older people.1,2 Incremental additions of medicines over time, multiple prescribers, medicines prescribed to treat the side effects of other medicines (prescribing cascade), and repeat prescriptions filled at different times and at different pharmacies can add to the complexity, and number of medicines used.1,3,4

Some people find it challenging and stressful to manage their medicines because of declining cognitive and physical abilities.2 Older people taking multiple medicines often have complicated dosing schedules requiring several administration times across the day.1 This substantial burden can affect people’s social, financial, physical and psychological well-being.1,5

When people can’t manage their medicines, they are more likely to have adverse outcomes, including inadequate symptom relief and ongoing poor health.6-8

This therapeutic brief provides information on how medicine regimens can become complex and outlines steps for reviewing the number of medicines used and simplifying the dosing schedule.

What makes a medicine regimen complex?

Multiple medicine use

The number of medicines taken is the strongest predictor of medicine-related harm.4 A snapshot of medicine use found 43% of Australians 50 years or older used five or more medicines routinely; 11% used 10 or more routinely.9 One in eight medicines is purchased from a supermarket, health food store or the internet, and a similar proportion is recommended by family, friends or the media.9

Using five or more medicines substantially increases the risk of adverse drug reactions, non-adherence, and disability and frailty in older people.1,10-12 Multiple medicine use in older people is also associated with increased rates of delirium, falls and fractures, functional and cognitive impairment, malnutrition and mortality.13 A study of older Australian veterans found one in four had at least one preventable medicine-related hospitalisation over a five year period and of these, a quarter had multiple preventable admissions.14

Frequent dosing schedules

Older people taking multiple medicines, especially those with limited literacy or cognitive skills, often find it difficult to coordinate doses, and self-administer their medicines more times a day than is necessary.15 They might not realise they can take different medicines at the same time, especially when directions are different. For example a medicine to be taken ‘twice daily’, and a medicine to be taken ‘every 12 hours’ are often taken at different times.15

The more frequent the dosing schedule, the less likely people are to take their medicines, or to take them at the correct time.16,17 A systematic review of 51 prospective studies indicated patients were significantly less likely to take their medicines, or take them at the correct time, if they took them two, three or four times a day, compared with once a day (see Figure 1). When directed to take medicines once a day, patients took them between 77% and 93% of the time.16

Poor adherence can have significant adverse outcomes. A US study showed patients with type 2 diabetes mellitus who missed multiple doses of an oral anti-hyperglycaemic in the previous month had worse health outcomes compared to those who missed only one dose. Patients who missed three or more doses had more days off work, increased diabetes-related healthcare use, poor glycaemic control, lower quality of life and less satisfaction with their medicines.8

Misinterpretation of directions

Misinterpreting directions is common; seemingly simple instructions can appear unclear and confusing to many patients, causing unintentional misuse and adverse outcomes.1,15 Older patients might change their lifestyle to take their medicines as they believe their doctor wants them to. For example, they might not leave the house so as to stick to a rigid dosing schedule or they might change their meal times unnecessarily, to accommodate taking their medicines.1 In some instances, the medicine regimen can dictate the person’s life.1

Multiple brand names, combination products and generic substitutions

Patients are often faced with different brand names, changes to formulations, and different colours and shapes of tablets and packaging.18,19 Older patients, in particular, often identify their medicines by colour and shape; when they change, they might stop taking their medicines or take a double dose.20

Steps to reviewing the medicine regimen

Reviewing medicine use, explaining options and potential outcomes for patients and aligning decisions with patient preferences has been shown to improve quality of life, give a sense of satisfaction and improve adherence.1,5,21 Because most patients like to participate in decisions about their health, making decisions with them, particularly those likely to be influenced by the patient’s values, preferences and care goals, is particularly important.22,23

When reviewing your patient’s medicines, consider the anticholinergic load, which is often caused by the administration of more than one medicine with anticholinergic effects. For advice on how to reduce the anticholinergic load go to: www.veteransmates.net.au/TB_anticholinergic

Refer your patient for an HMR

An HMR is an effective way to review your patient’s medicines, and identify the kinds of challenges and problems many patients with a multi-medicine regimen face in the home.21 Refer your patient for an HMR if you think they might be having difficulty managing their medicines or are unnecessarily overcomplicating their dosing schedule.24,25See the ‘Not sure of the Home Medicines Review process?’ insert to determine which of your patients might benefit from an HMR.

In the referral to the pharmacist, document that the reason for the HMR is to review all medicines, and where possible, adjust the dosing schedule to better fit in with the patient’s day-to-day life.25 To make sure your patient gets the most out of the HMR, explain the process to them; many patients are unaware of HMRs, their purpose or benefits.26 Encourage your patient to talk openly with the pharmacist about the daily routine of taking their medicines (see Box 1). Ask your patient to book in for a follow-up appointment after the HMR to discuss medicines that may require review.

Box 1: Having a conversation with the patient7,21,22,27

Allow the patient to talk about their experiences to find out:

If there is anything they would like to ask about their medicines

What medicines they might be taking that they don’t view as medicines, for example medicines purchased from the supermarket or health food store and creams, or eye drops

What aspects of medicine taking they find difficult, for example correctly storing medicines, cutting tablets, or following directions

If there is anything about their medicines they would like to change

If there are any medicines they don’t like taking

What they expect to gain from taking their medicines and whether they feel those expectations are being achieved

What their main goals are with regard to their health and treatment overall

If they experience any side effects from their medicines

If they are prepared to trial any changes to their medicines.

Simplify the dosing schedule: the pharmacist’s role

During the HMR the pharmacist confirms all medicines used by the patient, identifies any challenges or issues the patient might be experiencing, and helps to simplify their dosing schedule, following the steps outlined in Figure 2.

Figure 2: Simplifying the dosing schedule – a guide for the pharmacist1

Step 1. Ask the patient to ‘walk you through their day’ starting from when they wake up. Let them tell you in their own words, about all the medicines they currently use, and how and when they take them across the day. Asking questions from Box 1 may prompt a discussion and provide you with further information about whether taking their medicines affects physical, psychological or social aspects of their daily life and whether they take their medicines as directed.

Step 2. Fill out ‘My current medicine routine’ with the patient Write down all the medicines the patient currently takes, how and when they take them, and how they fit or do not fit in with their daily activities. Ask the patient to tell you what they understand each medicine is for. Let them demonstrate their competency in the use of any devices they have. Consider the anticholinergic load. On completion, show the patient how many times a day they are taking medicines and how much of their day is organised around their medicines. Clarify any medicine names and directions for use if required.

Step 3. Fill out ‘My new medicine routine’ with the patient Invite the patient to talk openly about their day and what their preferences might be for taking medicines. Discuss options for linking their medicines to their needs and daily activities. Where possible and appropriate, reduce dosing frequency and dosage units, eliminate tablet cutting and recommend a suitable adherence aid.

Step 4. Provide feedback to the patient’s GP Encourage the patient to take the completed ‘My new medicine routine’ form with them to the follow up appointment with their GP. In a written report to the GP, identify medicines needing further review and any other feedback.

Review the number of medicines used

On receipt of the written HMR report, discuss the results with the pharmacist.24 Follow the steps in Figure 3 to help guide the order and mode for changing or deprescribing medicines.

Figure 3: Reviewing the number of medicines used – a guide for the GP21,27,28

Step 1. Review all medicines Review and compare the medicine list received from the HMR report with your current medicine list in your record. Discuss any differences found with your patient and update your current medicine list as appropriate. Ask the patient for their ‘My new medicine routine’ list.

Step 2. Assess medicine-related benefits and risk of harm, and discuss options with your patient Take into account the number of medicines used, high-risk medicines, past or current toxicity and the patient’s individual circumstances and preferences (see Box 1). Ask your patient if they are aware of and understand their options, and explain probable outcomes of continuing or discontinuing medicines. Consider your patient’s age, cognitive ability, dexterity problems, comorbidities, other prescribers, and past or current adherence.

Step 3. Assess and consider the ongoing need for each medicine with your patient

Step 4. Prioritise medicines to be changed Discuss, prioritise and plan any changes with your patient; ask them what they want. Decide and agree on specific medicines to change, generally one at a time in a stepwise approach.

Step 5. Implement the plan and monitor the patient In collaboration with your patient, initiate the changes, and monitor and support them as necessary. Develop a Medication Management Plan with your patient and communicate the plan to the accredited pharmacist, community pharmacy and your patient.

Case study: Reviewing the medicine regimen – the final result

Mrs Jones, 87 years old, lives alone, does not go to her doctor often and has been taking the same medicines for many years. Her GP refers her for an HMR.

She is taking her medicines multiple times a day. She feels exhausted and weak, has stopped attending social functions, and feels stressed about the number of medicines she is taking. Mrs Jones has purchased paracetamol from the supermarket and is taking two, four times a day for muscle aches and pains, which her GP is unaware of. She has put the aches and pains down to getting older. She is spending most of her day taking her medicines as she believes her doctor would like her to.

The pharmacist talks with Mrs Jones about what her expectations are regarding her medicines, health, treatment and quality of life. The pharmacist shows Mrs Jones how to align her dosing schedule with her day, by filling out the two forms provided during the HMR.

It is likely Mrs Jones’ simvastatin was causing her muscle aches and pains, and weakness. After a discussion with the pharmacist and Mrs Jones, the GP ceases the simvastatin, trials a cessation of the frusemide, and changes the risedronate to a once a month dose, and the nifedipine and metformin to a controlled release form. Mrs Jones now spends much less time taking her medicines each day. She no longer has muscle aches and pains or feels so exhausted and stressed. She has resumed her social outings with friends and is enjoying life again.

Not sure of the Home Medicines Review process?

A Home Medicines Review (HMR), conducted by an accredited pharmacist in collaboration with the patient, can help patients better understand, organise and safely manage their medicines in the home.29

The MBS item number for an HMR (Domiciliary Medication Management Review) is Item 900. The benefit is claimable only on completion of all components of the process.24

Benefits under this item are payable once only in each 12 month period, except where there has been a significant change in the patient's condition or medicine regimen requiring a new HMR, for example, when a new condition is diagnosed or when starting a high-risk medicine, such as an oral anticoagulant. The patient’s invoice or Medicare voucher must be marked to indicate the HMR was required to be provided within 12 months of another HMR.24

How the pharmacist can simplify a dosing schedule during an HMR25

Recommend a higher strength to reduce the number of dosage units for a specific medicine where two tablets of the same medicine are taken at different times in a day

Recommend a lower strength product where the person is cutting tablets in half or into quarters

Consolidate dosing times to fit in with the patient’s lifestyle

Recommend a combination product if suitable to reduce the number of medicines being used

Recommend a suitable adherence aid for the patient with cognitive or dexterity issues.

How will an HMR benefit my patient?

HMRs have been shown to:

reduce medicine-related harm30,31

delay time to next hospitalisation32,33

help patients to better understand, organise and safely manage their medicines34

increase patients’ self-confidence and independence in managing their medicines30,34

improve communication between GPs, pharmacists and patients.34,35

Who is eligible for an HMR?

An eligible patient must be:

a current Medicare or Department of Veterans’ Affairs (DVA) cardholder

living in a community setting

at risk of or experiencing a problem with their medicines, and identified by their GP that they are likely to benefit from an HMR service.29

Getting the best out of the HMR for your patient

Assess the patient to determine if there is a clinical need and whether they are likely to benefit from an HMR (see Box 1 for people likely to benefit from an HMR).

Discuss the benefits and processes of an HMR with your patient and obtain consent.

Refer the patient directly to an accredited pharmacist of your choosing or allow the patient to take the referral to their usual community pharmacy. (Most medical software provides HMR referral templates.)

With the patient’s consent, give the pharmacist relevant clinical information for the review. To get the most out of the HMR process for your patient, specify the reason for the HMR in the referral. For example, if the patient is having difficulty managing their medicines, ask the pharmacist to simplify the medicine regimen and ascertain the patient’s ability to manage their medicines.

On receipt of the written report, discuss the results and suggested medicine management strategies with the accredited pharmacist.

Ask your patient to make a follow-up appointment with you to discuss medicines for review and possible changes.

The pharmacist usually provides a medication management plan. Offer a copy of the agreed plan to the patient and accredited pharmacist and give the patient’s community pharmacy a copy.24

Box 1: People likely to benefit from an HMR24,25

People likely to benefit from an HMR:

are having difficulty managing their medicines or using five or more medicines routinely, including over-the-counter or complementary medicines

are taking medicines multiple times a day or using multiple formulations, for example tablets, devices, creams and drops

have multiple co-morbidities

have had significant changes made to their medicine regimen or started a new medicine in the last three months, especially if the new medicine carries a high risk of adverse outcomes or has a narrow therapeutic index

are using a medicine that is not having the desired therapeutic effect

are suspected of non-adherence or are having difficulty in managing medicines related to a therapeutic device

have been recently discharged from hospital

are experiencing symptoms suggestive of an adverse reaction to a medicine

have a number of prescribers, including GPs and specialists, or other authorised prescribers, including dentists, or naturopaths, or

are having difficulty managing medicines because of dexterity problems, impaired sight or cognitive impairment, increasing frailty or language or literacy difficulties.

Gnjidic D, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. Journal of Clinical Epidemiology. 2012; 65: 989-995.

Roughead E, et al. The effectiveness of collaborative medicine reviews in delaying time to next hospitalization for patients with heart failure in the practice setting: Results of a cohort study. Circ Heart Fail. 2009; 2: 424-428.

Roughead E, et al. Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans. Journal of Clinical Pharmacy and Therapeutics. 2011; 36: 27-32.

PROVIDED BY: University of South Australia - Quality Use of Medicines and Pharmacy Research Centre

IN ASSOCIATION WITH: Discipline of General Practice, The University of Adelaide | School of Public Health, The University of Adelaide | NPS MedicineWise | Australian Medicines Handbook | Drug and Therapeutics Information Service

Topic materials available on this website reflect information current at the time of distribution. Images on this website and in Veterans’ MATES publications are stock images from photo library sources. They do not picture Department of Veterans’ Affairs staff, clients or constituents, or imply that the individuals pictured have the medical conditions discussed in Veterans’ MATES articles.